Utilization Management of Inpatient Admissions
The patient, his/her attending physician, or the office staff, calls CARE Network’s toll-free telephone number to give the Nurse Coordinator pertinent information regarding the patient’s diagnosis and health status. The Nurse Coordinator will establish the appropriateness of inpatient admissions and the length of stay using nationally recognized medical criteria, and his/her own clinical experience and judgment as a registered nurse. The Nurse Coordinator and the attending physician/Hospital Utilization Review department will discuss the patient’s condition and determine the appropriate treatment plan. The treatment plan can then be monitored and discharge planning facilitated through CARE Network’s Concurrent Review process. Pre-certification of inpatient admissions includes confinements for acute care, mental health, and chemical dependency.
Outpatient Utilization Management
CARE Network has developed a review program for outpatient surgical procedures. Once the employee is informed that a surgical procedure is recommended, the employee or physician contacts CARE Network’s Nurse Coordinator. If the procedure is determined to be medically unnecessary, a second surgical opinion or alternative treatment would be suggested, if your plan allows for this.